INurse. Faculty at University of
Fortaleza. holder of a CNPq fellowship. rmsilva@unifor.brIINurse. member of the research Group on Women's Health, University
of Fortaleza. Fortaleza, CE, Brazil. sanches.mariana@gmail.comIIINurse of the Family Health Strategy in the municipality of Aratuba,
CE. Member of the Research Group on Women's Health, University of Fortaleza.
Fortaleza, CE. nara_livia@hotmail.comIVM.Sc. in Collective Health. Physiotherapist in the municipality
of Uruoca, CE. Full Professor at Instituto Superior de Teologia Aplicada. Sobral,
CE, Brazil. aleudineliamonte@bol.com.brVNurse. Faculty at Federal University of Ceará. Fortaleza,
CE, Brazil. socorro@ufc.br

Most breast tumors are detected by women, not
health professionals, therefore breast self-examination (BSE) continues to
be an efficacious strategy. The study objective was to analyze BSE performed
by nursing professionals and factors that hinder their perseverance in this
practice. This descriptive study was performed with 159 professionals: 40
nurses, 48 nurses aides, and 71 health agents from 19 Basic Health Units
located in Fortaleza (Ceará, Brazil). Data collection was performed
using a self-administered questionnaire, and the analysis was based on the
Self Care Theory. Of the 159 professionals, 86 (54%) performed BSE on a monthly
basis. Of the 73 professionals who did not perform BSE, 60 (82%) reported
the reason for that was forgetting, 38 (52%) for not trusting the technique/did
not know the correct technique, and 35 (48%) due to lack of health care.
It was found that although most women reported performing BSE, the professionals
felt insecure and would like to learn better about this technique.

Breast self-examination (BSE) is a painless,
cost-free and easy physical exam that allows premature detection of a neoplasia
enabling efficient therapeutical action, all of which may extend the patient's
life, avoid future and severe physical sequelae as well as emotional, social
and economical problems(1). This examination is also extremely
important so the woman it able to have better knowledge of her breasts typical
aspects, such as shape, size, skin and nipple texture; all of which will
greatly assist in the early diagnosis of any abnormality that may arise and,
thus, lead to premature diagnosis, maybe avoiding breast mutilation.

Systematic breast self-exams are recommended
since the 1930's and have been incorporated into public health policies in
the US since the 1950's. When performed monthly and correctly, this exam
can increase the chances of early cancer detection leading to better treatment
and more favorable diagnostics(2,3).

The World Health Organization (WHO) estimates
that 1,050,000 new cases of breast cancer arise annually in the world(4).
Breast cancer affects women in their bio-psycho-social and spiritual dimensions,
as it is considered a disease whose medium and long term consequences may
cause breast mutilation and psychological, psychospiritual and social traumas,
including anxiety, despair, fear and depression and other serious repercussions
in the family among which death can also be cited(5).

Breast cancer is more common in women. The National
Cancer Institute (INCA) estimates that in 2008, 49,400 women will be diagnosed
with breast cancer in Brazil; the death rate will be of 51 cases in every
100,000 women group. In the Northeast region, the death rate if of 28.4 cases
and in the state of Ceará it is of 35.65 cases for every 100,000 women(1).

Even though the cause of breast cancer is still
considered idiopathic, some factors appear to increase the risk of developing
it. Some of the are genetical factors, emotional conditions, hormonal alterations,
and diabetes. Added to the list of risk factors is the occurrence of such
neoplasia in younger and younger patients(1).

Nursing professionals which work in primary
health care services can give information and orient patients on the correct
realization of BSE. According to the normative and recommendations of the
Ministry of Health for the control of breast cancer published in 2004, educational
actions must be developed through breast palpation of the patient's own breasts
by herself as a strategy for body care(6).

The lack of care for oneself, possibly caused
by the patient's demotivation before the ever-increasing amount of household
chores she is responsible for contributes to the increase in late cancer
diagnoses in young women while in their flouring productive ages.

The self-exam constitutes a form of care for
the self and the person's engagement in health actions, since it is carried
out by the person herself, for her own benefit, through activities or actions
that may satisfy her own necessities, be them physiological, developmental
or behavioral. Therefore, the theory of Self Care has been chosen which is
defined as the group of activities which a person carries out consciously
and deliberately towards his benefit for the maintenance of life, health
and his well-being(7). It determines that the agent of self-care
should be able to satisfy its own necessities, identifying limitations and
defining what may or must be done to improve health conditions. It proposes
the development of human skills, under the influence of basic conditioning
factors, such as age, sex, development state, health state, sociocultural
orientation, family system, life standards, environmental factors, adequation
and availability of resources. The requirements for self-care are comprised
of actions aimed at the provision of knowledge and necessary practices to
human development functioning and maintenance(7).

In a previous study done with university students
from health areas, it was observed that 68.5% of them did not perform BSE
monthly(8). Given this information and considering some significant
obstacles for the practice of self-care in health areas, answers were sought
after for the following inquiries: Are nursing professionals aware of the
importance of early detection of breast cancer? Are they attentive to the
importance of doing the breast self-exam? Which factors contribute for the
disregard of touching their own breasts? What leads to the woman deciding
not to take care of herself?

Faced with such problems, it was attempted to
analyze the practice of breast self-examination by health-professionals and
the factors that interfere with this practice.

METHOD

A descriptive study with a quantitative approach,
aiming at amplifying the experience about reality in the practice of breast
self-examination by nursing professionals, regardless of race, age, color,
marital status, number of children and social standards.

The research was carried out with professionals
from the nursing personnel of 19 Basic Health Care Units for Family Welfare
inserted in the Regional Executive Secretariat (SER) VI from the city of
Fortaleza in the state of Ceará. These units attend to a population
of approximately 500,000 people, representing the largest geographical area
among the regional secreteriats, which act according to the principles of
SUS with one or more than one family welfare teams.

Based on the population of 311 professionals
that worked at SER VI, a non-probabilistical sample was chosen, by quota,
and in each subgroup of nursing professionals, a quota, proportional to the
total number of professionals was selected; because by using quota sampling
the researcher uses his knowledge about the population to bring some representation
to the samples. When working with quota samples, a layer of the population
is identified and a number of elements necessary to this sample is specified.
Using information about the composition of the population, the investigator
can assure that all possibilities are represented(9).

To determine the sample, the following formula
was used: N=1/E² where N=sample size and E²=tolerated standard
error equivalent to 10%. A minimum sample size of 100 professionals was encountered,
but it was preferred to use a larger sample of 159 professionals to give
it better significance. The group was formed by 40 female nurses, 48 licensed
practical nurses and 71 community health agents (ACS). The criterion to select
the professionals was that they should be in contact with families engaged
in educational actions and applying strategies for health promotion and disease
prevention in their workplace and in the community.

Data collection was performed between January
and April 2007 using a self-applying questionnaire composed of two parts.
The first part contained questions for personal identification and life style,
and the second was composed of questions referring to breast cancer, self-care
and possible factors which could interfere with BSE. The questionnaires were
answered in the basic health care units, under acknowledgment from the unit's
supervisor. The participants signed a term of free will to the participation
in the study granting them full confidentiality in the terms of the information
obtained and the right to stop participating in the study at any given moment.
So to preserve their identity, their names were not revealed at any moment.

Data were pooled and organized using SPSS (Statistical
Package for the Social Sciences) platform version 11.5 making use of descriptive
statistical analysis, thus verifying distribution, and absolute and relative
frequencies for each variable according to the professional category.

As data analysis was based on the Theory of
Self-Care(7) and it was decided to use the developmental related
to human development process, and the factors which could influence this
evolution at some stage of the vital cycle. Therefore, the chosen events
for the research are aimed at the care of the self, behavioral changes and
life style.

This study was approved by the Ethics Committee
of the University of Fortaleza - UNIFOR, according to report number 269/2004
abiding by all ethical aspects from resolution 196/96 from the Health Ministry.

RESULTS AND DISCUSSION

Among the 159 participants, the prevailing levels
of school education found were at the High School level composing 107 participants
(67.3%), and University Degrees composing 38 participants (23.9%). Among
the 40 female nurses, three (7.5%) had taken a specialization course and
one (2.5%) had a master's degree. One of the licensed practical nurses (2%)
had not concluded her higher education. From the 71 community health agents,
62 (87.3%) had concluded high school, five (7%) had not concluded elementary
school, two (2.8%) had not concluded their higher education and one (1.4%)
had not concluded high school. It was observed that the workers had satisfactory
knowledge of health care to attend to the patients and to use it in their
own favor and the community's. The licensed practical nurses and the community
health agents, although numerically small, are very interested in improving
their knowledge of the cited matters.

Among the participants, 145 (91.2%) lived with
their families, 105 (66%) had been born in Fortaleza, 74 (46.5%) were married
and 135 (84.9%) declared not having any type of vices. The age for the menarche
of the participants varied from nine to 18 years of age, prevailing in the
interval from 11 to 14. This information indicates that these women, possibly,
had or have a healthy life-style, favoring health promotion and life quality.

Although 91 (57.2%) of the women do not practice
physical exercises for their vanity, they showed satisfaction towards their
physical appearance, because 140 (88.1%) appreciated their body and 134 (84.3%)
appreciated their breasts. This condition facilitates the self-understanding
of the body and it makes it easier to identify the alterations that may need
higher attention for health maintenance and to avoid further damage.

The care of the self implies being intimate
with your body, felling it, embracing it and respecting it. Caring is to
be tuned with the rhythm and to stay with it. Caring means to have a loving
relationship with reality; your investments of zeal, devotion, solicitude,
attention, and protection for what is worthy and interesting for the person.
Care for your health is commonly revealed in the actions of self-care(10).

Self-care's goals are the actions that may contribute
specifically for the integrity of functions and for human development. These
purposes are expressed before actions, whose grounds is to help people satisfy
their own therapeutical necessities of self-care(7).

From the 159 nursing professionals, 86 (54.1%)
performed BSE monthly and, among these, 64 (40.3%) did it after having their
period, 8 (5%) did it before having their period, three (1.9%) during it,
two (1.3%) did it on a fixed day of the month and one, during and after having
her period.

These results show that, even though 54.1% of
the patients do conduct BSE on a monthly basis, there is still controversy
about the ideal moment for such practice, which must be done monthly between
the seventh and tenth day after the beginning of the menstruation period,
but for women that no longer menstruate due to menopause or hysterectomy,
or for those who are breast feeding a fixed day of the month should be chosen
to carry out the self exam(11).

Breast self-exam, preconized as an early detection
method of mammary nodules is an efficient and low-cost exam. However, when
done sporadically, its results are as inefficient as when done incorrectly.
For one author(2), 80% of the tumors are detected by a woman when
she touches herself, whereas another author(3) considers that
up to 90% of breast cancer cases are detected by the patients themselves.

Among the evaluated professionals, 145 (91.2%)
declared to know how to perform the breast self-exam, and all nurses claimed
to master the correct technique. Among community health agents, 30 (42.2%)
claimed to do the procedure once a month and, among these, 88.4% guaranteed
to know very well how to do it. However, 87.5% stated that would like to
learn it correctly. This paradox was also noticed in the other groups, making
us question their degree of understanding of the technique when it comes
to breast self-examination.

BSE is of great importance because it is practical
and it helps the woman familiarize herself with the size and shape of her
breasts, and, furthermore, to recognize the normal aspects of the skin, giving
her better comprehension of when to look for medical help because something
is out of the ordinary with ample time. During BSE, the woman must examine
symmetry, color, shape, skin retraction and nipple retraction, swelling,
fissures and any other considerable alteration. One of the recommended techniques
for breast self examination is circular palpation, starting from the nipple
and slowly descending to the skin of the breast and axilla. This technique
was determined as the most widely accepted for a group of nursing students
in a study to evaluate the knowledge and lack of self-care about this particular
topic. This experiment demonstrated that there is much resistance and that
there are barriers to make breast self-examination a common procedure, but
it also reveals the wish, will and effort of these women to learn how to
do it correctly(12).

Among the participants, 41 (25.8%) had already
had a problem with their breasts and 73 (45.9%) had had a case of cancer
in the family, either from their mother, aunt or grandmother.

According to INCA, women diagnosed histopathologically
with atypical proliferating mammary lesion or in situ lobular neoplasia
have a high risk of developing breast cancer. For this reason, the attention
with health and BSE practice must be stimulated(11).

Among the 41 participants who had had a breast
problem, 25 (60.9%) examined their breasts monthly, showing attention for
self-care and assuming a responsible position towards their health. Even
though the state of caring for the self flourished in the individual when
he finds himself in a state of necessity(13) and even after observing
in this study that 16 women had already had some king of mammary pathology,
they did not report this feeling nor the habit of self-examination.

By using BSE as an early detection method for
breast cancer and believing in the instruction of the woman to fulfill it,
it is seen in the cited method a means for recognition of the neoplastic
disease in an early and curable stage(14). When diagnosed prematurely,
the chances of curing a breast cancer case might reach 95% and it probably
will not be necessary to mutilate the breast. Considering the lethality of
this disease and its physical and emotional sequelae, one may say that an
early diagnosis is of absolute and paramount necessity(2).

Among the 159 participants, the 73 professionals
(45.9%) that did not perform BSE regularly were 41 community health agents,
19 licensed practical nurses and 13 nurses. They reported as interfering
factors for BSE: forgetting it, 60(82%); lack of attention for their health,
35 (47.9%); they did not trust their own technique/did not know the correct
procedures, 38(52%); were afraid of the disease or afraid of finding nodules,
21 (28.7%); did not believe in BSE, 17 (23.3%); did not know the importance
of early diagnosis, 12 (16.4%); did not like to touch their body or were
ashamed of doing so, 11(15%); stated not having had any cancer cases in the
family and were not old enough to develop breast cancer, 10 (13.7%) and seven,
(9.6%) because they believed they would never be affected by it.

The reason most widely cited for not performing
the exam monthly was forgetting it, which was reported by 13 (100%) of the
nurses, 33 (80.4%) community health agents and 14 (73.6%) licensed practical
nurses. A possible reason for this is the fact that the brain is more likely
to store strong emotions while others tend to last very little and, if not
repeated, will be forgotten due to lack of practice and repetition. Memory
if exercised regularly grows bolder, but if not worked with will dissolve
itself into oblivion(15).

Most people only pay attention to their own
memory when it fails, particularly when lapses lead us into embarrassing
situations or prevent us from concluding an important activity. Many believe
that forgetting is something bad, undesirable and say that would like to
have a better memory. This is perfectly comprehensible if one thinks on the
many times we become frustrated because we have forgotten something. Even
though it is hard to reject the hypothesis of losing information due to the
lack of use of our memory, people are led to believe in the idea that information,
once stored, will not be passively lost, even if not accepting that one can't
remember everything(16).

Another barrier cited by the 35 (47.9%) professionals
that did not carry out periodical self-exams was the lack of attention for
their own health, claimed by 17 (41.4%) community health agents, 11 (57.8%)
licensed practical nurses and seven (53.8%) nurses. This information leads
us to believe in the development of actions aimed at self-care, since it
is possible to draw a correlation between the care for the self and the good
governing of a town; only those that care enough about themselves can care
about others. This particular self is, at the same time, subject and
object to be cared about, it is the soul that uses the body, a subject-soul of
instrumental action, of relations with itself and others in behaviors and
attitudes(3).

Those who care appropriately about themselves
find conditions to relate and conduct satisfactory relationships with others.
For these relationships to be conducted adequately and deliberately it is
necessary that each one of us takes good care of oneself, and of the others
with competence and continuous improvement, for the individual and collective
well-being. Therefore, caring about oneself means, above all, caring with
liberty and criterion both about others and ourselves, including our passions(13)

In this study, both the 24 community health
agents and the 19 licensed practical nurses, 14 (73.7%) and 24 (58.5%) respectively,
claimed not to trust their own techniques or not to master the technique
appropriately. This result shows that it is highly necessary that these professionals
receive proper training to develop their skills for the care of the self
and that of others. It is important to highlight that 22% of the community
health agents and 15% of the licensed practical nurses did not know the importance
of early cancer detection through BSE. As health professionals and women,
they must be very well informed and oriented when it comes to the exams for
early detection of breast nodules, which are many times aired in campaigns
from the Ministry of Health.

The awareness about the necessity of breast
self-examination starts with showing the importance of this procedure by
the health team that works in the basic health care units. It is necessary
that these professionals be continuously informed about the importance of
BSE so they can supply the population with quality information, be it individually
or in groups. It is also important to use all resources available to facilitate
this practice for more women and their many ages and social contexts(17).

The information, knowledge and critical conscience
are determining factors for the execution of actions of self-care in health
programs and, therefore, must value the individual and collective well-being.

Any health professional that deals directly
with the population and is conscious of the epidemiological profile of the
patients can establish preventive and early diagnosis strategies for the
population in general. The relay of information is an efficient strategy
to develop potential in women and it is up to the nursing team to orient
such practice along the community.

For BSE to reach its objective of early detection
of breast cancer and consequently play a role in reducing mortality rates,
participative campaigns must be conducted to give concrete information about
the technique and the importance of self-care, along with incentives in education
so that the given information is incorporated and leads to changes in the
behavior of women. The propagation of these actions must be stimulated in
all supportive levels so that all social groups are effectively reached(5).

Approximately 39% of all community health agents
and 26% of all licensed practical nurses were afraid of breast alterations
or of having the disease. The nurses, on the other hand, did not claim to
be afraid, possibly for being more closely related to the scientific advancements
when it comes to the cited pathology.

Considering the impact that this disease has
in women, the possibility of losing her breasts and the impossibility of
prevention, is it very important that women have knowledge about the pathology,
the protecting factors and the methods to detect it in its early stages,
avoiding premature deaths and the disadvantages of the curing therapies(4).

In this study, there was a low frequency of
9.6% of women who believed that would never suffer from this disease, a piece
of information that can be considered preoccupying, because the simple fact
of being a woman constitutes the highest possible risk factor for breast
cancer. This type of cancer is the malignant neoplasia of highest occurrence
and highest lethality among Brazilian women, composing approximately 20%
of the cases of neoplasia in women and 15% of their deaths(3).

The embarrassment or the dislike for touching
herself was cited by 11 women, nine of which (21.9%) were community health
agents and one (5.3%) was a licensed practical nurse. The human being must
be seen biologically, psychosociologically and spiritually and must be capable
of making decisions of their own about their lives and of developing and
carrying out actions of self-care. By self-examining herself, the woman is
able to better understand her body and so she must feel comfortable with
herself.

BSE is an activity to be done by the woman throughout
her whole life to maintain and promote her well-being, and when effectively
done it may help maintain her integrity and contribute to the proper functioning
of the organism.

Breast cancer is a disease which cannot be prevented,
but its early detection favors excellent treatment possibilities, avoiding
physical sequelae and emotional distress, difficulty to re-interact with
the family, professionally and with other women. As a result, it is important
that more health care professionals know about breast self-exam and make
every possible effort to teach women to create and develop the habit of self-examining
themselves(2).

Because the resources granted to the population
are so restricted and limited, it is of prime importance to discover strategies
to correct this distortion and give women the means for early diagnosis of
breast tumors. BSE is certainly one of the most important steps in identifying
mammary tumors, mainly in populations of developing countries. Under these
conditions, breast self-examination becomes an auxiliary method for the early
detection of mammary neoplasia(17).

Nowadays, breast cancer is a pathology which
becomes more and more common among women. Therefore, this type of cancer
needs to be considered in its whole, because after the woman is stricken
by it, not only her body is changed but also her corporal image and different
aspects of her social and emotional lives(18).

The importance of this subject makes necessary
for an ample discussion so people become fully aware of the meaning it has
when a woman is sick from the very organ that makes her feel like a woman.
It is something that is far from being simple, it is full of anguish and
fear, but it must be taught little by little(18) according to
the experiences and life styles of each person.

In this study, it was observed that even though
there is a percentage of 54.1% of nursing professionals which perform BSE
monthly, INCA highlights that this exam should not replace the clinical exam
to be carried out by a health professional trained for this activity(4).

BSE is a practice which must be continuously
stimulated and oriented by professionals from health areas, so the woman
is better able to understand her own body and create the habit of examining
herself. It is made evident that conscience on the matter is of the highest
importance and for such there must be participation from all professionals
related to it, from the users of the health services to community leadership
to teach and expand the understanding and comprehension on breast self-examination(5).

CONCLUSION

In the present study, it was observed that most
of the professionals (54.1%) carried out breast self-examinations monthly,
however, the community health agents were the ones that least made part of
such group. BSE is an educational practice, a habit of self-care to be developed
in adult life.

Possibly, when the woman feels comfortable with
her body, she tends to develop practices of self-care. Strategies for education
in health-care must then be promoted, so women can better understand the
importance of the self-exam and so they have enough confidence to do it,
granting them physical, social and emotional well-being.

Breast cancer prevention is still incipient
and monthly self-examination must be stimulated because it is the most accessible
way to assist the woman in fighting this treacherous disease. Even so, BSE
must be associated with clinical exams and mammographies in order to guarantee
a safer approach to the problem and to increase the possibility of an earlier
detection. Furthermore, public agents must also have a clear conscience of
the importance of such practice so health care services can be properly carried
out.

It is suggested that activities in the studied
groups be increased to involve them in actions for health promotion through
seminars, courses and multi-professional orientation, informative resources,
educational campaigns, means of communication, participation in the control
of risk factors and continuous observation of the body.

This study may contribute to the development
of new researches related to the determining factors for the non-participation
in BSE based on population, identification of the required knowledge and
professional practice to teach this technique to the end-users, besides the
added information that can be used in nursing schools and in extension programs
within the community.